Monitoring patterns in adverse events to improve patient safety.

Thursday, 12 June 2008 04:00
Dr. Hazem El-Oraby

Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, writes about their experience with using triggers (a standardized set of criteria defining a certain condition) in BIDMC.

A year ago or so, I wrote about the introduction of our Triggers Program, a rapid response team approach to patients on medical floors who might soon decompensate or have other serious changes in their condition. The program has been incredibly successful in reducing mortality and morbidity. In fact the number of "codes" on our floors has gone down so dramatically that residents now need to practice emergency resuscitation mainly in the simulation center because so few actual patients need it.Here is how things are today at BIDMC. The nurse notices that the patient has developed a certain condition, based on a standardized set of criteria (Triggers). The nurse is required to call the doctor, the senior nurse in charge and the respiratory therapist -- and they all come to see the patient. They collaborate on a plan of care for the patient going forward. Regardless of the time of day or night, the intern/resident then calls the attending doctor in charge of the patient to let him/her know that the patient has "triggered".

In the year after implementation of the Triggers program, one of the major focuses of our reviews was on patients who had major adverse events happen in spite of the Triggers program. When these adverse events occurred, we tried to understand the factors that contributed to them even being possible in our organization. A few months after Triggers began, we began to notice some patterns. Here are some examples of the things we learned.

Oxygen is not a utility

Patients in the hospital sometimes need extra oxygen. Low oxygen levels in the blood can be due to pneumonia, heart failure, or a number of other problems. Surprisingly, extra oxygen usually does not help with the feeling of shortness of breath, but rather prevents further problems from not getting enough oxygen to vital organs. We found that, in many cases, providers often treated oxygen as a utility -- like the water that comes out of the sink – rather than as a drug used to support a feeling organ system. (The members of our Triggers Steering Committee had worked in about twenty other hospitals total, and we all felt it was the same in every hospital in which we’d ever worked.)

We saw a pattern in which providers would repeatedly increase the amount of extra oxygen that was being provided to patients. We often monitor the oxygen level in the blood through a noninvasive device -- as his number was normal, providers felt reassured – not taking into account the fact that the patient was needing higher and higher levels of artificial support to keep this number at the “right” level.

In fact, interns would sometimes round in the morning and would find their patients on oxygen with no explanation, and the patient had been breathing room air the night before. Sometimes, neither the nurse nor the intern knew why the patient got put on oxygen; it had happened overnight and was viewed as an unimportant event.

As a result of this we conducted a Failure Mode Effects and Criticality Analysis, a tool used in the military and industry to understand points at which complex systems are likely to fail, and implemented substantial changes in the ways that we order oxygen, in a way that patients are monitored from a respiratory standpoint. We also introduced physician, nurse, and patient care technician education on this matter.

Aspiration risk

We also learned that aspiration was a bigger threat to patient safety than was usually appreciated. When physicians and nurses talk about "aspiration" they are talking about when a patient swallows something the wrong way. This can be the person's own saliva and secretions or, more commonly, can occur when they try to eat or drink something. Since the mouth is usually full of bacteria, this can lead to pneumonia; sometimes, the person actually swallows his or her stomach acid in the lungs, which can lead to very severe chemical injury to the lungs. In some cases, aspiration leads to death. For this reason, when we think that someone is at high risk for aspiration, we put them on “aspiration precautions." This means that nurses, patient care technicians, and physicians are all alerted to the increased risk of this problem. In addition, we put a sign up on the patients at the patient's bedside to warn visitors and those providers who may be seeing the patient before seeing the chart.

As we dug a little deeper into some of these cases, we learned that patients sometimes aspirated food that their families brought in. Family members obviously did this out of love, but it sometimes led to very severe consequences for their loved one. When we tried to figure out why this happened, we found that our warning signs depended heavily on written English, rather than on easily interpretable symbols. This meant that if family members came to visit and English was not their first language, or if they had trouble reading English, we might not convey the right information to them. In coordination with a provider education campaign about the risks of aspiration, we therefore redesigned our signage to overcome these barriers – by using multiple languages and universal symbols (think Mr. Yuck!) that were likely to be interpretable even if the family member was unable to read the sign.

Who does what?

As inpatient medical care has become more complex, more people are needed to provide it. For example, our nurses do a number of safety checks as they're preparing various medications because these medications have inherent risks. There is also substantial amount of documentation that nurses have to do for safety, compliance, and legal reasons. This means that nurses need extra manpower to get work done. Most hospitals, therefore, have a group of providers who are variously known as nursing assistants, nurse’s aides, or patient care technicians. These providers are trained by the hospital, and sometimes by external schools, but are not licensed in the same way that nurses and physicians are. Patient care technicians may check vital signs, help with turning patients, assist with toileting, etc. In our hospital, for example, many of the routine vital signs are taken by patient care technicians. The Triggers program taught us a few things about patient care technicians and their relationships with our other existing systems of care. In particular, when we did our initial education for the Triggers roll out, we forgot to include patient care technicians in the educational campaign. This was a huge oversight, which we quickly learned when we would see patients who did not Trigger even though they had abnormal vital signs. Why didn't they Trigger? They didn't Trigger because we forgot to provide education to this very important a set of providers in our institution. Once we had included them in the educational campaign, this mechanism of Trigger failure essentially vanished.

We also learned that what patient care technicians do on any given floor is extremely variable. We therefore began a program to help standardize the scope of practice for patient care technicians at BIDMC.

Unintended consequences of improving patient satisfaction

A few years ago, as we tried to improve patient satisfaction, we changed the way that patients order their hospital food. The program was called “At Your Request" and let patients call up to order their meals from a menu of options – at essentially anytime they wanted to eat. However, this turned out to be another way that patients who were at high risk for aspiration (see above) could get food that was unsafe for them to eat.

If the nurse is worried, you should be worried too.

The Triggers Program has various specific criteria mandating a response from providers. For example, if the pulse rate is acutely greater than 130 beats per minute, a Trigger is called and the team responds. However, we have one criterion which is much more subjective: "marked nursing concern." When we implemented the Triggers program, many physicians were very nervous about giving this criterion. They were afraid that they might be called in the middle of the night for things that weren't really important, and that nurses might use this as a weapon if they did not like the physician or if they disagreed with the plan of care. Well, it turns out that nurses use this Trigger quite judiciously.